FOR me, the recent comments in InSight+ about the experiences of junior doctors with the current structures for training (here and here) highlight our failure to develop a cohesive long term plan to proactively adapt the medical workforce to meet contemporary expectations for work/life balance and the nature of medical practice in the 21st century.
The current state has arisen from the compounding consequences of responses to parochial short-term issues on a background of many decades of failure to look at the big picture. The fault lies with all of us: governments, universities, health service managers and our profession.
The creation of doctors is an expensive business largely funded, directly and indirectly, by government (the taxpayer) as an investment for the future of the health system, which is itself predominantly funded by government. While some may tout the benefits of natural selection in an open marketplace, it seems wasteful of both money and human capital, unethical and thoughtlessly cruel to knowingly encourage some of the brightest of hopeful young minds to embark on a journey that leaves so many demoralised and will be, for some, a dead-end road.
The growth in the demand for junior doctors has been driven in part by the shift to more reasonable working hours. I will not go on about working horrendous hours in the 1970s and 1980s and the number of times that I fell asleep over dinner. Paradoxically, however, that intensity of work provided clinical experience that is hard to achieve in a 37-hour week, and poses a challenge for the design of training programs.
Simultaneously, the growth in the quantity and complexity of knowledge about diseases and their treatment has dramatically increased the number of subspecialties while decreasing the range of the illnesses that individual doctors manage. Many patients now have several specialists involved in their care and every public hospital specialist requires an intern and/or resident to undertake the practical work, along with registrars to oversee them.
Unfortunately, in the absence of an overarching plan that considers broad-scale and long-term consequences, the edifice of public hospital specialist practice is now supported by a vast base of junior doctors employed to cover the shifts required for the hospital system’s mandated standard working week, and who allow us to continue to work in the manner to which we have become accustomed. However, these numbers have not been matched by sufficient specialty training positions nor, in turn, by the prospect of subsequent specialist jobs for all medical graduates.
In my field of palliative medicine there are about 130 advanced trainees (3 years’ full-time equivalent [FTE] advanced training). While a number of us are retiring every year, I find it hard to believe that state governments will fund an ongoing annual growth of perhaps 30 FTE consultant positions. I understand that we are not alone and that the marketplace of available jobs is becoming saturated for a number of other specialties, particularly in large cities.
So, how can we address this problem?
The first step is to consider the goals of a plan for a sustainable medical workforce. The outcome must provide for a reasonable working week, deliver high quality training and career opportunities for all medical graduates and, in the face of rapidly changing technologies, meet the needs of a community that expects round-the-clock, high quality, whole-person care.
In a steady state, and very crudely, if on average a doctor qualified at age 25, trained for 7 years to attain specialty status (GP or other) and subsequently worked for another 35 years (at say 0.8 FTE), then the ratio of total number of junior doctors to the total of those who are working and have completed their training would be a bit above 1:5. The number of doctors completing training would match the number of trained specialists (by definition including GPs) leaving the profession each year.
Of course, we do not live in a steady state. Sustaining an effective workforce structure would require active management of a complex dynamic balance between the number of doctors in training and the evolution of their career opportunities driven by science and technology. The problem is a bit like a complex multidimensional version of one of those high school maths exam questions that have two trains approaching each other at different speeds.
On the one hand, the intake of medical students, and consequently the number of doctors in training, should anticipate current and future workforce requirements. It should not be driven by the need to fill rosters for a 37-hour week.
On the other, in addition to meeting the current and future healthcare needs of the community, the number of specialists (particularly those working in public hospitals) must be adapted to the consequences for service delivery of a changed proportion of junior doctors. Included in this calculation is the significant amount of time necessary to educate the evolving numbers of medical students and doctors in training.
Variables include the variety of roles of all specialists, natural attrition rates, part-time work, parental leave, illness, career change, the needs of different communities, demographic change and changes in disease prevalence, task transfer to other health professionals and, not least, the evolution of medical practice and technology.
I cannot see any solution to this test of our ability to collaborate in solving complex problems that does not re-balance the structure of the medical workforce, including the roles and responsibilities of all doctors.
The first consequence would be an increase in the number of specialty training positions and a concurrent phased reduction in the number of medical students. The quality of training for junior doctors would also be enhanced by a greater emphasis on education and experience, and a reduced role in some aspects of service delivery.
The progressive reduction in the numbers of junior doctors would require the employment of higher numbers of specialists who would provide a higher proportion of direct patient care, including 24/7 rosters (just as many do now in private practice and in public hospital acute care; eg, emergency departments and intensive care units). The more intensive training needs of increased numbers of advanced trainees would also be met by the larger numbers of specialists. While raising challenges in terms of continuity of patient care and maintenance of skills, the numbers of specialists would have to match contemporary expectations for work/life balance.
Over time, the excess supply of junior doctors would be mopped up while patients should achieve better health outcomes (and experience lower risk) from having an increased proportion of their care being delivered by doctors who had completed their specialist training.
Managing such a transition would be a huge challenge. Governments, universities, medical colleges, health care employers and, most of all, doctors would have to accept that change was necessary and embrace a huge shift in their understanding of their roles and responsibilities. It would require leadership and a willingness to address the huge range of vested interests that benefit from the status quo of particular niches in our unsustainable medical workforce ecosystem.
This discussion may seem to have moved a long way from the distress voiced by individual young doctors. However, while the goshawks in the tree below my veranda may live by a strategy that is successful when one or two of their three hatchlings reach maturity, I am sure that is a high attrition rate is not acceptable for the training of doctors. Most of the selection of the fitter candidates occurs before admission to medical school.
Clearly, this article is deliberately provocative designed to stimulate discussion. I don’t think we can choose not to act.
Dr Will Cairns is a palliative medicine specialist based in Townsville and an Adjunct Associate Professor at James Cook University.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.